CONFRONTATION TEST
Meaning
The Confrontation Visual Field Test is a basic and quick screening method used in
optometry and ophthalmology to assess a patient's peripheral (side) vision. This test helps to
detect potential visual field defects that may indicate underlying eye conditions or
neurological problems.
JUSTIFICATION AND PURPOSE
1. The test helps identify defects in a patient’s peripheral vision, such as blind spots,
scotomas, hemianopia, or quadrantanopia, which could indicate underlying eye or
neurological conditions.
2 Since glaucoma can cause peripheral vision loss, this test helps in the early detection
and monitoring of this condition
3. Neurological Assessment
Stroke: Strokes can affect the visual pathways in the brain, leading to visual field defects.
This test helps in detecting such deficits
.4. Monitoring Known Conditions/ Progression of Disease: For patients with known eye or
neurological conditions, the test can help monitor changes in the visual field over time,
assessing the progression or improvement of the condition.
5. Efficacy of Treatment: Evaluating how well a patient is responding to treatment for
conditions that affect the visual field.
6.Pre- and Post-Surgical Evaluation
Pre surgical Baseline: Establishing a baseline of the visual field before surgery involving the
eyes or brain.
Post-Surgical Follow-Up: Assessing any changes in the visual field after surgery to
determine the impact or success of the procedure.
Performing the Confrontation Visual Field Test involves a straightforward procedure that can
be executed quickly and without any specialized equipment. Here is a step-by-step guide on
how to perform this test:
PREPARATION AND PROCEDURES
Environment:
Ensure the room is well-lit and with neutral background so as not to interfere with the Target
shown to the patient
Positioning:
Both the Doctor and the patient should be seated or standing at eye level, about 1 meter (3
feet) apart so as to operate on the same Visual Field
Also, the patient should remove his/her spectacle before the Test is carried out because the
Rim of the spectacle could create artificial visual field defects
INSTRUCTIONS:
1. Explain the test procedure to the patient, emphasizing the importance of looking
straight ahead and responding promptly
2. Firstly, with both eyes open let the patient look at the Doctor's Face and ensure there
is no missing part on the Doctors Face this is aimed at eliminating Gross Hemianopia
3. Covering One Eye:
Ask the patient to cover one eye with an occluder or their hand without pressing on
the eye. If the patient is covering their right eye, the examiner should cover their own
left eye, and vice versa, to match the visual field being tested.
4 . Fixation:
Instruct the patient to fixate on the Doctor's open eye or nose throughout the test
5. Testing Each Quadrant:
Upper and Lower Temporal Quadrants:
The Doctor extends their arm to the side, out of the patient’s view, and slowly brings
their fingers or hand inward from the periphery towards the center of the patient’s
visual field.
The Doctor asks the patient to say “now” or raise their hand when they first see the
moving fingers or hand.
Upper and Lower Nasal Quadrants:
Repeat the same procedure for the nasal quadrants by moving the fingers or hand
from the periphery toward the center of the patient's visual field.
6. Finger Counting:
Alternatively, hold up one, two, or three fingers in various quadrants of the visual field
and ask the patient to count the number of fingers they see while maintaining fixation
7. Static Object Detection:
Hold a static object, such as a small pen or a target, in different areas of the visual
field and ask the patient to indicate when they first see it.
8. Repeat for the Other Eye:
Cover the other eye and repeat the entire process to test the visual field of the
opposite eye.
For Blind spot assessment,
Blind Spot Location:
The natural blind spot is located about 15 degrees temporally (to the side) from the central
fixation point and slightly below the horizontal line of sight. This is due to the absence of
photoreceptors where the optic nerve exits the retina.
PROCEDURE
Static Object Test:
The examiner holds a small object (such as a pen or a small target) at the patient’s eye
level, directly in their line of sight, and then moves it slowly outward horizontally.
NB: A Red pen target is most commonly used reason being that the central portion of the
visual field is more sensitive to Red light.
Detection: The patient should indicate when they can no longer see the object as it moves
temporally. This helps identify the blind spot location.
Reappearance: Move the object further temporally and then back towards the center to
confirm when the patient can see it again. This should confirm the edge of the blind spot.
Vertical Movements: Move the object vertically (up and down) along the horizontal meridian
of the identified blind spot to assess its dimensions.
INTERPRETATIONS AND REPORTS
Interpreting the results of the Confrontation Visual Field Test involves analyzing the patient's
responses to determine the presence and type of visual field defects. Here is a detailed
guide on how to interpret the findings:
NORMAL RESULTS
Expected Response: The patient detects the examiner's moving fingers or hand in all
quadrants of their visual field without delay.
Conclusion: A normal confrontation test suggests that there are no gross visual field
defects. However, it does not rule out subtle or small defects that might require more
sensitive testing methods.
ABNORMAL RESULTS:
Abnormal findings in the Confrontation Visual Field Test can indicate various types of visual
field defects, each associated with different underlying conditions:
HEMIANOPIA
Homonymous Hemianopia:
Findings: Loss of the same side of the visual field in both eyes (e.g., the right half of the
visual field in both eyes).
Interpretation: Often caused by lesions in the contralateral optic tract, optic radiations, or
occipital lobe. For example, a left-sided brain lesion can cause right homonymous
hemianopia.
Heteronymous Hemianopia:
Bitemporal Hemianopia:
Findings: Loss of the outer (temporal) halves of the visual field in both eyes.
Interpretation: Typically associated with lesions at the optic chiasm, such as pituitary
tumors.
Binasal Hemianopia:
Findings: Loss of the inner (nasal) halves of the visual field in both eyes.
Interpretation: Less common,can be caused by lesions affecting the lateral aspects of the
optic chiasm.
Quadrantanopia
Findings: Loss of vision in one quadrant (one-fourth) of the visual field.
Interpretation: Caused by lesions in specific parts of the visual pathways. For instance:
Superior Quadrantanopia: Lesions in the temporal lobe or inferior optic radiations (Meyer's
loop).
Inferior Quadrantanopia: Lesions in the parietal lobe or superior optic radiations.
for blind spot assessment,
Normal Findings: The presence of a small, well-defined blind spot in the temporal visual
field of each eye, corresponding to the anatomical blind spot.
Abnormal Findings: Enlarged, multiple, or misplaced blind spots could indicate retinal or
neurological conditions, such as optic neuritis, glaucoma, or brain lesions.
Tips for Accuracy
● Ensure that the patient maintains fixation on the central point throughout the test.
● Move the stimuli at a moderate pace to allow the patient enough time to respond.
● Compare the results between both eyes to identify any discrepancies.
CONCLUSION
The Confrontation Visual Field Test remains a vital tool in the initial assessment of a
patient's peripheral vision. It is straightforward, requires minimal equipment, and can be
performed quickly in various clinical settings. Despite its limitations, the test provides
valuable information that can guide further diagnostic procedures and interventions. For
comprehensive care, any abnormal findings from the confrontation test should be followed
by more advanced visual field testing to confirm and characterize the extent of visual field
loss.
References
● Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and
Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.
● Pavan-Langston D. Manual of Ocular Diagnosis and Therapy. 7th edition.
Philadelphia, PA: Lippincott Williams & Wilkins; 2016.
● Bowling B. Kanski's Clinical Ophthalmology: A Systematic Approach. 8th edition.
Elsevier; 2016.
